Application

*Indicates a required field

Dealer/ Seller Phone:

Property will be:

Primary ResidenceNon-Primary Residence / SeasonalBuy-For

Purpose of the loan:

Purchase Home OnlyPurchase Home and LandRefinance

Last, First, & Middle Name*

Are you a citizen?*

YesNo

Martial Status*

UnmarriedMarriedSeparated

Define your living situation:

HomeownerRenterLiving with ParentOther

What do you intend to do with the existing home?*

What is your monthly mortgage/rent?*

Are you currently employed?*

YesNo

Self-employed?*

YesNo

What kind of employee are you?*

HourlySalary

How often are you paid?*

WeeklyBi-weeklyMonthly

How many hours a week do you work?

How much do you make per hour?

What is your gross base pay rate (before taxes) per pay period excluding commission, bonuses, and overtime?*

Do you receive commission or bonuses?*

Commission/Bonus Amount: (Put '0' if none)

Do you receive overtime?*

Overtime Amount: (Put '0' if none)

Previous Job Position Held*

Previous Job Date Started*

Previous Job End Date*

Applicant's Other Income

Income for SSI, retirement, disability, alimony, child support, or other separate maintenance agreement need not be disclosed if you do not wish to have it considered as a basis for undertaking or repaying this debt.

Do you receive income for court mandated child support?*

Child Support Monthly Amount

Age(s) of Child(ren) (multiple separated by comma)

Do you receive income for alimony or separate maintenance?*

Alimony or Separate Maintenance

Do you receive other income such as SSI, Retirement, Disability, etc?*

Other Income

SSIRetirementDisabilityOther

Applicant's Debts/Obligations

Are you mandated by court to pay child support?*

Child Support Monthly Amount

Are you mandated by court to pay alimony or separate maintenance?*

Alimony or Separate Maintenance

Additional Questions:

Are you a co-maker or a guarantor on a note?*

Have you had any judgements, repossessions, garnishments filed against you in the past 7 years?*

Have you declared bankruptcy within the last 10 years?*

Demographic Information - this section asks about your ethnicity, sex, and race

The purpose of collecting this information is to help ensure that all applicants are treated fairly and that the housing needs of communities and neighborhoods are being fulfilled. For residential mortgage lending, Federal law requires that we ask applicants for their demographic information (ethnicity, race, and sex) in order to monitor our compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to provide this information, but are encouraged to do so. The law provides that we may not discriminate on the basis of this information, or on whether you choose to provide it. However, if you choose not to provide the information and you have made this application in person, Federal regulations require us to note your ethnicity, race, and sex on the basis of visual observation or surname. The law also provides that we may not discriminate on the basis of age or marital status information you provide in this application.

Instructions: You may select one or more designations for "Ethnicity" and one or more designations for "Race." If you do not wish to provide some or all of this information, select the applicable check box.

Ethnicity: Check one or more

Hispanic or LatinoNot Hispanic or LatinoI do not wish to provide this information

Race: Check one or more

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteI do not wish to provide this information

Name of enrolled or principal tribe:

Asian origin:

Pacific Islander origin:

Native HawaiianSamoanGuamanian or ChamorroOther Pacific Islander

Latino origin:

MexicanPuerto RicanCubanOther Hispanic or Latino

Sex

MaleFemaleI do not wish to provide this information

Do you have a co-applicant?*

Co-Applicant Information:

Co-Applicant Last, First, & Middle Name*

Co-Applicant Birthdate*

Co-Applicant Social Security #*

Co-Applicant Martial Status*

Co-Applicant Email Address

Co-Applicant Phone Number*

Co-Applicant Address*

Co-Applicant Zipcode*

How long? (in months)

Define your living situation:

What is your monthly mortgage/rent?*

Co-Applicant Current Employer*

Co-Applicant Self-employed?*

Co-Applicant Date Started*

Co-Applicant Job City*

Co-Applicant Job State*

What kind of employee are you?*

How often are you paid?*

How many hours a week do you work?

How much do you make per hour?

What is your gross base pay rate (before taxes) per pay period excluding commission, bonuses, and overtime?*

Do you receive commission or bonuses?*

Commission / Bonus Amount: (Put '0' if none)

Do you receive overtime?*

Overtime Amount: (Put '0' if none)

Co-Applicant Previous Employer*

Previous Job Position Held*

Previous Job Date Started*

Previous Job End Date*

Co-Applicant's Other Income

Do you receive income for court mandated child support?*

Child Support Monthly Amount

Age(s) of Child(ren) (multiple separated by comma)

Do you receive income for alimony or separate maintenance?*

Alimony or Separate Maintenance

Do you receive other income such as SSI, Retirement, Disability, etc?*

Other Income

SSIRetirementDisabilityOther

Co-Applicant Additional Questions:

Are you a co-maker or a guarantor on a note?*

Have you had any judgements, repossessions, garnishments filed against you in the past 7 years?*

Have you declared bankruptcy within the last 10 years?*

Co-Applicant's Debts/Obligations

Are you mandated by court to pay child support?*

Child Support Monthly Amount

Are you mandated by court to pay alimony or separate maintenance?*

Alimony or Separate Maintenance

Co-Applicant Demographic Information - this section asks about your ethnicity, sex, and race

Ethnicity: Check one or more

Hispanic or LatinoNot Hispanic or LatinoI do not wish to provide this information

Latino origin:

MexicanPuerto RicanCubanOther Hispanic or Latino

Race: Check one or more

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteI do not wish to provide this information

Name of enrolled or principal tribe:

Asian origin:

Pacific Islander origin:

Native HawaiianSamoanGuamanian or ChamorroOther Pacific Islander

Sex

MaleFemaleI do not wish to provide this information

This concludes the questions for the co-applicant. At this end of this application, the co-applicant will be required to e-sign.

Sales & Transaction Information:

Loan Type

Home OnlyLand/HomeLand-In-Lieu

Manufactured Home Information:

Home Size (Width)*

Home Size (Length)*

Housing Intent*

Primary ResidenceSecondary Residence / Seasonal

Land or Lot Payment*

Street Address Where Home Will Be Located*

Site Placement*

Did you do a trade-in?

YesNo

Trade-In Manfacturer Make*

Trade-In Manfacturer Model*

Trade-In Home Size (Width)*

Trade-In Home Size (Length)*

Down Payment - Was any borrowed or gifted?*

YesNo

Land / Home Combination

Land Purchase Price or Payoff

Land Appraisal Value

Septic / Sewer Hookup

Less Encubrances (Lens)

Other (Sidewalk, other site improvements, etc.)

I/We certify that the information stated is complete and accurate, and has been furnished by me (us) knowing that you intend to rely on it in considering my (our) application. I (we) understand that you may request a consumer report in connection with this application and for the purpose of updating, renewing or extending further credit, and, if I (we) ask, I (we) will be informed whether or not such a report was requested (and, if so, the name and address of the consumer reporting agency that furnished the report). I (we) agree that this application remains the property of MHD Empire Service Corp. whether or not a loan is granted. I (we) also authorize you to check my (our) employment/income history and to exchange account and credit information about me (us) with anyone you may ask. To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying information. It is a crime to intentionally falsify information on this application.

For applications with more than one applicant, signing the Applicant and Co-Applicant each agree the intent is to apply for joint credit.

Co-Applicant Signature:

What is the best way to contact you?*

EmailPhone CallText

When is the best time to contact you?*

Is there any information you wish to disclose in relation to this loan?

Demographic Information was provided through:

Contact

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GET IN TOUCH

+1 866 870 2612

mhdemp@haylor.com

300 South State St, Suite 1000
Syracuse, NY 13202
Company NMLS #51371

MHD Empire's Secure Online Credit Application

Basic Information:

How long at present address (Since when?)

Applicant's Other Income

Applicant's Debts/Obligations

Additional Questions:

Demographic Information - this section asks about your ethnicity, sex, and race

Co-Applicant Information:

How long at present address (Since when?)

Co-Applicant's Other Income

Co-Applicant Additional Questions:

Co-Applicant's Debts/Obligations

Co-Applicant Demographic Information - this section asks about your ethnicity, sex, and race

Sales & Transaction Information:

Manufactured Home Information:

Land / Home Combination

Certify and Sign

Contact Preferences

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